For the third time I heard " (name ) if you read my brochure, you will realize that I don't say it definitely." 
I have read the brochure about 4 times but because of that, am reading again.

what's the brochure's name? Dr.J's handwritten brochure about  Thyroid eye disease ~*

Proptosis, lid retraction, diplopia, optic nerve compression, strabismus, thy name is  Thyroid/Grave's disease.

Thyroid eye disease is interesting. These are so far, things I have observed and maybe noticed traits of patients with this pathology. (perhaps because I was told that the patient is often by my much experienced predecessors)

• talkative (have to cut them in middle of conversation while I'm screening, or else I will fall behind...)
• may not be pleasant.
• sometimes aggressive/paranoid

However, although I might have met paranoid person, luckily I have not had any extensive unpleasant experience... actually I can only recall seeing friendly thyroid patients who might have been more talkative than other patients.

*side note: what I do when I see thyroid patients. I write the code 0906A.

What's weird is that Thyroid eye disease (or thyroid orbitopathy, Grave's disease, Grave's orbitopathy etc) is an autoimmune disease that occurs in people 'with a history of thyroid problems...[but]...occur before or decades after the development of thyroid gland disease.' Another curious thing is that it can manifest even after the thyroidectomy. WHY?!?!? you don't have thyroid, so shouldn't you be free from these problems? 

Actually I just found out through U of M website, that ophthalmic manifestation is divided into 2 groups.  

Hypermetabolic and infiltrative 

(http://www.kellogg.umich.edu/theeyeshaveit/acquired/graves-disease.html)

Hypermetabolic: excess thyroid hormone --> sympathetic pathway activation --> retraction of lids 

= the "stare sign" -- when the patient is to look downward, the upper eyelids remain elevated or begin moving downward only after a delay -- a sign called "lid lag" 

Infiltrative: lymphocytic infiltration of the orbital soft tissue, NO RELATIONSHIP to the LEVELS of the THYROID hormone. 

so that's why Mr.K, even after thyroidectomy had this problem. back to it being an autoimmune disease...

As the inflamed conjunctiva becomes hyperemic (red) and boggy, the eyes tear and discharge mucus. The patient reports a feeling of tightness (yes), irritation (yes), and intermittent blurring of vision (yes), much as one might experience with infectious conjunctivitis ("pink eye"). The lower eyelids become boggy, and palpation elicits a sense of rubbery induration that is only mildly tender.

When the extraocular muscles and orbital fat become inflamed, the eyes are displaced forward in the orbit (proptosis, exophthalmos), and the movements of the eyes may be limited. At first, the impaired eye movements are due to swollen, inefficient extraocular muscles. If the inflammation persists beyond a year, the muscles scar in a contracted, noncompliant state. Typically, some extraocular muscles are affected more than others, driving the eyes out of alignment in some fields of gaze, and causing the patient to experience double vision.

As the muscles swell, they may compress the optic nerve in the posterior orbit, where they are packed in a tight space. If the compression is not relieved, axoplasmic flow within the nerve comes to a halt, and vision fails. This compressive optic neuropathy is the most dreaded ophthalmic consequence of Graves' disease.

Another outcome of marked swelling of extraocular muscles and orbital fat is massive proptosis which interferes with the protective function of the eyelids and results in drying of the cornea. This "exposure keratopathy" is the second most feared ophthalmic manifestation of Graves' disease.

The combination of hypermetabolic and infiltrative ophthalmic signs gives away the diagnosis of Graves' disease.

But when the hypermetabolic component is absent and infiltrative signs are mild, the condition is often misdiagnosed as infectious or allergic conjunctivitis.

When one side is relatively spared, the physician may incorrectly diagnose an orbital tumor.

And when inflammation relatively spares the most visible tissues—the conjunctiva and eyelids—the physician may fail to consider Graves' disease as the explanation for diplopia or visual loss.

But Mr.K had other problem. and that is what prompted me to write this post. He developed a Retinal Hemorrhage (bleeding behind retina) so he has to get injection in his eye with a needle ever 3 weeks in addition to chronic predinisolone drops.

"What were you injected with", I asked.

" Oh, I'm not sure..."

"Is it the steroid?"

"Oh, I use that drop everyday, but it's not that."

Dr.J must know. surely. 

So I asked Dr. J and he answered "anti-VEGF" 

Vascular endothelial growth factor.
as VEGF encourage the development of new blood vessel so in order to stop the evolution of bleeding. You use this. The most commonly marketed drug for this. LUCENTIS.
I asked if this anti-VEGF is must be used for cancer and he said yes..
Turned out the drug named AVASTIN is used to treat colorectal, lung, breast and brain cancer. The difference is that LUCENTIS is used specifically for the eyes and therefore smaller molecule.


It amazed me that this procedure was just implemented 3 years ago.
Before it was all corticosteroid.





side note:

Retinal Hemorrhages

Shape Mechanism Common Associated Conditions Dot Hemorrhage Rupture of deep capillaries Diabetes Flame Hemorrhage Rupture of superficial pre-capillary arterioles, small veins Systemic hypertension, leukemia, severe anemia, thrombocytopenia, retinal vein occlusion, trauma Boat Hemorrhage Rupture of large superficial retinal veins into the space between the retina and vitreous; sometimes these bleeds break into the vitreous cavity Sudden increase in intracranial pressure, anemia, thrombocytopenia, trauma Submacular Hemorrhage Rupture of choroidal vessels under the fovea Age-related macular degeneration Vitreous Hemorrhage Rupture of superficial retinal vessels or vessels on a fibrovascular stalk extending into the vitreous Proliferative diabetic retinopathy, hypertension, trauma

November 06 2012 - Lessons with Dr.J

If you ask me if I know someone who is an ideal husband, without a second thought I would say Dr.J.
The way he approaches the problem so logically with grace, you can almost say that I idolize him ("I never met anyone so perfect....") and then there is this love he has for his wife..that makes him the perfect husband.
(Women are often more attracted to hard-working men!)

Anyways, during the sloppy day it was yesterday, very important lessons were taught to me.


Do I want to be data gatherer, or a problem solver?


Why was the patient 20/400 in one eye and 20/20 in the other?
What was the reason? follow follow follow. Just like Sherlock Holmes would, look for clues that will tell the 'story'.
This was the very important lesson that was taught and I shall remember it.




Mental disease: Morgellon's disease
--why did I write Mental disease? it was described me to as a skin condition and I just typed up mental before I looked up the definition from Wikipedia.

Morgellons (also called Morgellons disease or Morgellons syndrome) is a name that was given in 2002 by Mary Leitao^[1] to a proposed condition characterized by a range of cutaneous (skin) symptoms including crawling, biting, and stinging sensations (formication); finding fibers on or under the skin; and persistent skin lesions (e.g., rashes or sores). Doctors,^[2] including dermatologists^[3] and psychiatrists,^[4] regard Morgellons as a form of delusional infestation (also called delusional parasitosis), i.e. the belief that there is a pathogenic infestation despite contrary medical evidence.^[5]

Despite the lack of evidence that Morgellons is a novel or distinct condition and the absence of any agreed set of diagnostic symptoms,^{[6][not in citation given]} the Morgellons Research Foundation and self-diagnosed Morgellons patients successfully lobbied members of Congress and the U.S. government's Centers for Disease Control and Prevention (CDC) to investigate the proposed condition.^[2][7] The CDC researchers issued the results of their multi-year study in January 2012, indicating that there were no disease organisms present in Morgellons patients, the fibers found were normal clothing fibers, and suggested that patients' sensations were manifestations of "delusional infestation".^[8][9]




Lambert-Eaton syndrome: (LEMS often associated with lung cancer... 50-70%)

Lambert–Eaton myasthenic syndrome (LEMS, sometimes Lambert–Eaton syndrome or Eaton–Lambert syndrome) is a rare autoimmunedisorder that is characterised by muscle weakness of the limbs. It is the result of an autoimmune reaction, where antibodies are formed against presynaptic voltage-gated calcium channels in the neuromuscular junction (the connection between nerves and the muscle that they supply).^[1]Around 60% of those with LEMS have an underlying malignancy, most commonly small cell lung cancer; it is therefore regarded as a paraneoplastic syndrome (a condition that arises as a result of cancer elsewhere in the body).^[2]

People who develop LEMS are usually over 40, although it may occur at any age. The diagnosis is usually confirmed with electromyography and blood tests; these also distinguish it from myasthenia gravis (MG), a related autoimmune neuromuscular disease.^[1]

If the disease is associated with cancer, direct treatment of the cancer often relieves the symptoms of LEMS. Other treatments often used aresteroids, azathioprine and intravenous immunoglobulin, which suppress the immune system, and pyridostigmine and 3,4-diaminopyridine, which enhance the neuromuscular transmission. Occasionally, plasma exchange is required to remove the antibodies.^[1]

Canaliculitis

One of the most misdiagnosed condition and this family physician wonderfully got it right.
The infection was caused by none other than Actinomyces Israelii and it is half yeast/bacterial like infection that is managed by minor surgery and antibiotic.

Actinomyces israelii is a species of rod-shaped bacteria within the Actinomyces. Known to live commensally on and within humans, A. israelii is an opportunistic pathogen and a cause of actinomycosis. Many physiologically diverse strains of the species are known to exist, though all are facultative anaerobes.^[1]

Actinomycosis is most frequently caused by Actinomyces israelii and is sometimes known as the "most misdiagnosed disease,"^[who?] as it is frequently confused with neoplasms. A. israelii is a normal colonizer of the vagina, colon, and mouth. Infection is established first by a breach of the mucosal barrier during various procedures (dental, GI), aspiration, or pathologies such as diverticulitis. The chronic phase of this disease is also known the "classic phase" because the acute, early phase is often missed by health care providers. This is characterized by slow contiguous growth that ignores tissue planes and forms a sinus tract that can spontaneously heal and recur, leading to a densely fibrotic lesion. This lesion is often characterized as "wooden." Sulfur granules form in a central purulence surrounded by neutrophils. This conglomeration of organisms is virtually diagnostic of Actinomyces israelii.^{[citation needed]}

Trabeculectomy : for Glaucoma

Surgical procedure used in the treatment of glaucoma to relieve IOP by removing part of the eye's trabecular meshwork and adjacent structures :: most common INVASIVE glaucoma Sx::

Allows drainage of aqueous humor from within the eye to underneath the conjunctiva where it is absorbed.



Procedure:
1. initial pocket is created under the conjunctiva and Tenon's capsule and the wound bed is treated for several seconds to minutes with mitomycin C (MMC, 0.5–0.2 mg/ml) or 5-fluorouracil (5-FU, 50 mg/ml) soaked sponges. why? to inhibit fibroblast proliferation.

2.  A partial thickness flap with its base at the corneoscleral junction is then made in the sclera after careful cauterization of the flap area

3. a window opening is created under the flap with a Kelly-punch to remove a portion of the sclera, Schlemm's canal and the trabecular meshwork to enter the anterior chamber

4.  Because of the fluid egress the iris will partially prolapse through the sclerostomy and is usually therefore grasped to perform an excision called iridectomy.(This iridectomy will prevent future blockage of the sclerostomy)

5. The scleral flap is then sutured loosely back in place with several sutures. The conjunctiva is closed in a watertight fashion at the end of the procedure.


Characterized by the bleb on sclera/cornea and pressure  can not be applied on the eye. 

Most relaxing weekend.

Everything going back to normal now (at least the work and research-wise), or rather lax with the vacation certain someone is taking ;)

However, I am still in midst of submitting application for U of W, U of A, U of C and U of T, Q and M.
I realize right now...even though it is most expensive (therefore torturous), it would probably be my happiest moment, being all hopeful and all. I shudder at the thought when my fate becomes sealed.

This year and next year might be ok (financially!) but what about afterwards? Not having profession, not putting my education to use, not doing....

I shudder at the thought...about the failure and gloom future.


Another thing I am most looking forward might be the life as a student.
No real responsibility of an adult I suppose, or postponing it.

Whorfian hypothesis (Whorf, 1956), a hypothesis named after a sociolinguist Benjamin Lee Whorf. Noting diversity across how different languages, especially through observation of how drastically native American languages such as Hopi is different from what he called Standard European Languages (SEL), Whorf argued in his writings that our perception of the world is like “kaleidoscopic flux of impressions” and language curves it in any arbitrary way. In this sense, language determines thought.

The Secret to Happiness?
1. Keep a Gratitude Journal
2. Exercise, Meditate & Eat Better
3. Share Random Acts of Kindness
4. (What's Your Suggestion?)

Harvard

I'm in love with Harvard shhhh

Pension - unfair government and fat cats

Get ready to pay billions for hydro pensions

Special to Financial Post  Aug 31, 2011 – 6:55 PM ET | Last Updated: Aug 31, 2011 7:02 PM ET

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Think hydro rates are outrageous now?

By Catherine Swift and Bill Tufts

Wonder why Ontario hydro rates are so high? There are many reasons for soaring electricity rates, but one that hasn’t received anywhere near enough attention is the very lavish pay and benefits of the hydro utilities’ staff.

Recently, there has been quite a ruckus over a number of pensions in the extended public sector. In British Columbia, it was revealed that a senior executive at BC Ferries was eligible to receive a lifetime pension valued at $315,000 after only nine years of employment there. In Quebec, Hydro-Québec claimed that its pension costs last year were only $21-million, but its financial reports showed that taxpayers had pumped $646-million into the pension plan. Stay tuned — we will hear many more such horror stories as a result of decades of pension underfunding, early retirements and rich pensions of public sector workers and those in the extended public sector.

As a result of some of these outrageous recent examples, we decided to investigate the Ontario electricity situation. A recent executive compensation report from Ontario Power Generation (OPG) shows it is on track to pay its CEO a lifetime pension of $720,000 annually or $60,000 per month or $2,000 per day starting at age 65. Assuming an average lifespan, the CEO will collect total pension payments valued at about $17.6-million. Various other executives at OPG are shown to be eligible to receive pensions of $490,000, $330,000 and $310,000 per year according to the OPG report.

This seems to be part of a government trend in Ontario. Last year, the Sunshine List showed more than 11,000 workers making more than $100,000 a year at Hydro One and OPG. When fully eligible, they will receive a pension of at least $70,000 (as public-sector workers typically receive a pension valued at 70% of final salary), including CPP. Current data show that, for a person retiring today at age 55, their life expectancy is now 84. This means that the numerous Sunshine List employees will each collect a pension of at least $2-million.

Defenders of these very generous pensions always claim that these employees contribute their fair share into the pension plans, and so deserve them. As taxpayers, we would normally think a 50-50 split of contributions would be fair, with employees contributing 50% and taxpayers matching it. But over the past five years alone, taxpayers have pumped $1.3-billion into the plan, while employees have contributed only $368-million. Not so fair and sure to create serious pension tensions when taxpayers find out what is really happening in these pension Ponzi schemes.

With all this money having gone into the plan recently, one would think that these pension contributions would mean the plan is solvent. Not so. OPG still had an estimated pension deficiency on a wind-up basis of $2.8-billion with the last valuation that was due on Jan. 1, 2011. Since the report has not yet been released, it is likely the shortfall is even worse than the $2.8-billion reported.

Unfortunately, the story does not stop here. Both Hydro and OPG pay for generous benefits for its retired employees — benefits that are rarely if ever seen in the private sector. Called Other Post-Employment Benefits (OPEBs) in the lingo of pension experts, these allowances are primarily for enhanced health care for employees after they retire. OPG owes a debt to its future retired employees of $1.9-billion in OPEBs, and Hydro One owes almost $1-billion. Given expectations that healthcare costs will skyrocket in the next few years, the real costs faced will very likely be much higher than even these significant amounts.

This is only one narrative regarding the hydro utilities in one province. Multiply this times so many other arm’s-length government agencies at all levels of government, across all the provinces, and you start to get an idea of the massive obligations that will soon fall on private-sector taxpayers and ratepayers for utilities like hydro. Think hydro rates are outrageous now? You ain’t seen nothin’ yet.

Financial Post

Catherine Swift is president of the Canadian Federation of Independent Business. Bill Tufts is an employee benefits specialist at WB Benefit Solutions and author of the upcoming book, Pension Ponzi.

http://opinion.financialpost.com/2011/08/31/get-ready-to-pay-billions-for-hydro-pensions/

Working on short projects make me feel little more confident, little more worthy, and little more alive. (also the fact that I decided to write 1000 words/day and has not even started  was addressed partially with this work which ended up being 4000+ words)

+

Today I worked on essay questions/answers wrote by a mom for her son and at first I was little disturbed by words of her choosing and found it quite hysterical because it was so generic and stereotypical. 

However, I did find it little heart warming and son's achievement was quite amazing too... To be able to achieve such high grade. Perhaps it was my jealousy, because son also aimed to be a doctor being born in the family of doctors. I could feel bitterness in my tongue when I describe it to my mom.

And then much after midnight (after submitting) I visited post secret to kill my time (sorry time, it's not that I want to kill you, but it sort of just happens blame my sloth!) I saw this postcard

Ah...my evil, bad mouthing self melting

D-1

There are long-term goals and short-term goals.
By not having any commitment, I make myself available, but I wonder now if that's a good thing.

What I want to say to people around me (at the store) what I will be doing this year proudly. instead. of making weird faces and mumbling "oh~ I don't know"
I want to be able to open my facebook again so I can creep up people to see what they have been up to.
I want closure? I want to be able to move on with my life (in the wanted direction of course...not the other way such as repeating this year), instead of being a parasite and showing my little sister, how pathetic her older sister is (no job, no money to buy home the list is endless!).

I want to not having to update my freelancing website every 15 minutes to see if a new job has come up, excited at the prospect and become crestfallen to see that another bidder was selected instead (who had bidden higher than me too, as an extra punch). I want the freedom to enjoy the time off (travel? that I would do!), instead of being all anxious and wasting the day so treasured by those that passed away a day before.


I don't want plan B

Saussure

-          language tool of representation (language is a structured system of representation)

-          one way to think about language as representation  = signs

-          linguistic sign unites as a concept (signified) and sound-image (signifier)\

-          (linguistic sign) the relationship between signified and signifier is arbitrary

-          Language only a system of pure value : ideas and sounds

-          Language is not nomenclature, it allows us to perceive the reality

-          Language is a form connecting sound and thought

-          Language is a system of INTERDEPENDEN term in which the value of each term results solely from the simulataneous presence of others

o   Signs combined like links in 2 ways

o   Syntagmatic: all units present in articulation

o   Associative: related present in mind but absent from actual sequence

-          In language there are only differences that are positive

-          Ways in which value can be determined (how is value different from signification):

o   Dissimilar things exchanged for determined values

o   Similar things compared for determined value

-          Saussure’s linguistic distinction between language or the whole system as it exists on the abstract level (Langue and Parole)

Nietzsche

-          Is language full and adequate expression of all realities?

-          Account of languages role in human cognition

-          Gap between first metaphor is big (subject and object)

-          Concept comes into being by making equivalent that is non equivalent

Poe

-          Words or even letters are signifiers – creating poetic effect

-          Language shapes experience

Derrida

-          Thinks about metaphysics included in the language

-          Deconstruction not a theoretical metalanguage – western metaphtsics do binary opposition and hold one privileged over the other

-          Refute the idea that there is only one meaning – deconstruction; there are multiple meanings in the text, often opposite; for example in dissemination, he talks about Plato’s Phaedrus; recorded conversation between King and the God who gives writing as told from Socrates to ponder about writing and speech and in Plato’s phonocentricism, Derrida notes the irony that supremacy of speech is only told through writing (spoken signifier can contain the essence of its signified is logocentrism)

-          Il n’ya pas de hors-texte (there is nothing outside the text)

-          Supplement: talks about writing and supplement; why would we need it? (ie.// preface in the
book) – copy and original (when you read the text, your experience is repetition, copy of text; through copy original is defined

-          Trace and difference

o   Signifier (image-sound) works as a trace that gives the impression that a signified was prior to it

o   Difference  - verb to defer and to differ – shows the  temporal structure of language – always changing in more than one way

o   Signifier points to other signifiers

Lacan – agency of letter in unconscious

-          Conducted psychoanalysis using Saussure’s method

-          Unconscious is structured like language

-          Signifier can change you; signifier used  as treatment

-          Signifier priority over signified why? Because this sound-image structures out existence, so by talking you change something about yourself.

-          Language can transform meaning language is capable of deception

-          Language is possible of distorting meaning through 2 ways

o   Metaphor associated with resemblance – condensation (love like a rose)

o   Metonymy associated with no resemblance – replacement of something entirely different (sails/ hand)

-          Signifier replace one signifier with another

-          While Derrida says we can’t arrive to truth because one signifier other signifier, Lacan says opposite that since signifier can signify another signifier, we can arrive to truth. (or your truth exists somewhere)

-